Topic: Wardwise Treatment Guidelines For Intern Doctors

1. Sedative poisoning Diagnostic tools:1. H/O of taking sedatives e.g. Sedil, lexotanil, Bopam etc.2. Pt. may be disoriented or drowsy or in deep sleep.3. Respiration is normal or depressed.4. Planter reflex is normal or extensor.5. Pupils mid dilated & sluggish reaction to light.Management:1. Diet- normal, plenty of tea, coffee by mouth if Pt. can swallow2. NPO till recovery, If pt. is in deep sleep.3. O2 inhalation 1-4 L/min, if respiration is depressed.4. Infusion 5% DNS 1000 i/v @ 10 drops/ min.5. Activated charcoal (Tab. Ultracarbon 2+2+2), if pt. present with in 1 hour.6. Antidote of Benzodiazepine- Flumazenil, slowly IV, dose 0.2 mg over 30–60 seconds, repeated in 0.5 mg increments as needed up to a total dose of 3–5 mg.Flumazenil is a benzodiazepine receptor-specific antagonist; it has no effect on ethanol, barbiturates, or other sedative-hypnotic agents. Flumazenil should not be used in pt. with H/O seizures or in patients with preexisting seizure disorder, toxin induced cardio toxicity, co-ingestion with TCA. The duration of action of flumazenil is short (2–3 hours) and resedation may occur, requiring repeated doses.Activated Charcoal: Activated charcoal effectively adsorbs almost all drugs and poisons. Poorly adsorbed substances include iron, lithium, potassium, sodium, mineral acids, and alcohols. (Ref. CMDT 2010)2. Tricyclic antidepressant poisoning (Tryptin)

Clinical features1. H/O taking TCA drugs in over doses ie. Amitryptylin2. Dilated pupil, ileus, and retention of urine.3. Respiration may depressed. 4. Presence of arrhythmias in ECG may present5. Hypotension may occur6. Hyperreflexia with extensor plantar, coma, and seizures.7. Improvement can be expected within 24 h.

Management1. NPO till further order or recovery.2. IV fluids infusion (5% DNS1000cc +5% DA1000cc i.v. @20 drops/min. stat & daily) 3. Gastric lavage may be given after delayed presentation.4. Tab. Ultracarbon 2+2+25. Treatment of arrythmias6. If convulsion present Diazepam and phenytoin.7. ECG monitoring during the first 24 h and until ECG changes have disappeared for 12 h.8. If acidosis present- IV sodibicarbNote: Sodibicarb available at 7.5% 25 mlTips: • Gastric elimination may be useful for 24 h after ingestion because tricyclics slow gastric emptying.• Cardiac arrhythmias are more common if there is acidosis. Bicarbonate should be used to achieve an arterial pH of 7.5 urgently.• If arrhythmias occur with no acidosis and fail to respond to treatment with amiodarone or phenytoin, bicarbonate (25-50 mL 8.4% IV) may still be useful with in 20 min.• If VT compromising cardiac out put, Lidocaine 50-100mg i.v. should be given.(Ref. Oxford American Hand book of critical care + Parvin Kumar & M. Clark)

Tips:1. Dilution or neutralization, induction of emesis, gastric aspiration and lavage are contra-indicated.2. Emulcents- egg white, olive oil, butter, cold milk should be avoided.3. As there is no specific antidote, symptomatic treatment is to be provided. Neutralization with alkali now a days is not done.4. Surgical treatment must be considered for any pt grade ll or lll esophageal injury.5. Diagnostic Endoscopy should be performed within 12-24 hours of alkali ingestion.6. Corticosteroids have no role in the management of a case and complication. It is rather harmful.7. Soluble calcium tablet followed by 10% ca gluconate IV can be given in acid ingestion.8. 1% NaHCO3 irrigation may be given in eye involvement with steroid eye drops. ( Ref. National guideline for management of poisoning)

Tips:1. If stomach is full, no forceful emesis should be tried.2. Specific antidote: (l) Physostigmine 0.5 mg to 1 mg s/c to antagonise atropine in a single dose. (ll) Prostigmine is more effective and less toxic than physostigmine in same dose. (lll) Pilocarpine 5 mg s/c, though useful, does not counteract the action of Dhatura on brain, can be repeated 2 hourly at early stage of poisoning.3. Delirium can be treated with short acting barbiturates.4. To control marked excitement chlorolhydrate or paraldehyde in moderate dose may be given.5. Repeated purgation is not recommended.6. Forced diuresis is not encouraged.7. Light diet, mainly liquid or semi-liquid should be given if the condition is mild.8. Other symptomatic treatments.

1. Should be hospitalized and must be treated by an ophthalmologist for his visual problems.2. Stomach wash although advocated, there is no evidence of affectivity with it.4. In severe cases pt should be incubated and mechanical respiration should be given.7. Acidosis should be controlled by infusing sodium bi-carbonate.8. Sedation can be given cautiously to prevent delirium and restlessness.9. The antidote for methanol poisoning is ethanol.

Tips: a) Treatment should be restarted when pt. symptomatically well and S. Bilirubin and SGPT become normal. b) Where there is no scope to do S. Bilirubin and SGPT then Rx. Can be restarted 14 days after the urine or eye become normal. Ref: Nation guideline of management of tuberculosis.

10. PneumothoraxManagement:1. Bed rest2. O2 inhalation3. Treatment of the underlying cause if any e.g. Pnemonia, COPD etc.4. Water sealed drainge(percutaneous needle aspiration)- Indication: i. Immediate decompression prior to definitive therapy in tension pneumothorax ii. In open or close pneumothorax- Pt. age < 50 years with pneumothorax > 15% of hemithorax or significant dysponea.5. Intercostal tube drainge i. Tension pneumothorax ii. Pneumothorax with underlying chronic lung disease e.g. COPD iii. In open or close pneumothorax -Pt. age > 50 years with >15 % of hemithorax or significant dysponea iv. When >2.5 L air aspirated or Pneumothorax persists after percuteneous needle aspiration (water seal drainage).Indication of Surgery in pneumothorax: 1. In all pt. following a second pneumothorax2. Following first episode of primary pneumothorax Surgeries are -Pleurodosis. (Can be achieved by pleural abrasion or parietal pleurectomy at thoracotomy or thoracoscopy).

11. Empyema thorasicsManagement1. Draining of the pus- intercostals tube drainge2. Antibiotic iv co-amoxiclav or Cefuroxime plus metronidazole3. Surgical intervention- if IT tube not providing drainge, when the pus is thick or loculated.4. Surgical decortication of lung – if gross thickening of the visceral pleura is preventing re-expansion of lung.

NB:  IV hydrocortisone can be replaced by oral steroid after 24-48 hours. Costly regimen- Inhaler Salmetrol & Fludicasone combination. 2 puff 12 hourly. (gargling after use).Antibiotic should be other than the previous one that was used in last 3 month

5. Combined ACEi & ARBIndication-HF pt. in those with recurrent hospitalization for HF.6. Beta blocker therapy More effective than ACEi in reducing mortality. Bisolol starting dose at 1.25 mg daily increase gradually over 12 weeks to a target maintainance dose of 10 mg daily.7. Digoxin To provide rate control Also in NYHA III, IV8. Amiodarone- Effective in pt. of symptomatic arrhythmia- Should not be used in asymptomatic arrhythmia.4. Valvular heart disease

Aortic stenosisIndication of surgery in Aortic stenosis1. Development of angina2. Development of syncope3. Symptoms of low cardiac output4. Heart failurePt. with moderate to severe stenosis is evaluated every 1-2 year with Doppler Echocardiography to detect progression of severity.

Indication of surgery in aortic regurgitation 1. Symptomatic pt.2. Asymptomatic pt. should be followed up annually with Echo for evidence of increasing ventricular size, if this occurs or if the end systolic dimension increases to ≥ 55mm the aortic valve replacement should undertaken.

Mobilization and rehabilitation In uncomplicated casesa) Sit on chair on 2nd dayb) Walk to toilet on 3rd dayc) Return to home on day 5 to 7 d) Gradually increasing activity & return to normal work in 4 to 6 week In complicated cases-Process of mobilization & rehabilitation varies & depends upon the pts functional capacity.